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South Dakota rates for HCPCS L3702

Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$220.01 / $220.01 / $220.01
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$169.87 / $186.86 / $218.82
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$176.75 / $180.09 / $346.63
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$367.13 / $367.13 / $458.91
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$218.82 / $369.81 / $1,474.48
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$127.53 / $204.04 / $345.61
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$288.20 / $346.63 / $542.80
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$283.87 / $351.50 / $662.38
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$267.02 / $312.60 / $371.57
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.49 / $164.63 / $335.72
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$299.36 / $299.36 / $299.36